A nurse is conducting a mental status examination. Which of the following questions should the nurse ask to determine the client's insight?

"Do you feel you need treatment?"

"Who is the governor of this state?"

"What do you get when you subtract 7 from 100?"

"How do you get money for your needs?"

Answer and Explanation

The Correct Answer is A

A. "Do you feel you need treatment?"
Asking the client, "Do you feel you need treatment?" assesses their insight into their own mental health condition. Insight refers to the client's awareness and understanding of their illness, including recognizing the need for treatment. A positive response to this question indicates the client's awareness of their condition and willingness to seek help, demonstrating good insight.

B. "Who is the governor of this state?"
This question assesses the client's orientation to time, place, and current events. It is useful for assessing cognitive functioning but does not specifically measure insight into one's own mental health.

C. "What do you get when you subtract 7 from 100?"
This question assesses the client's cognitive functioning, specifically mathematical abilities. It is useful for evaluating cognitive skills but does not address insight into mental health.

D. "How do you get money for your needs?"
This question assesses the client's problem-solving abilities and understanding of practical matters. It is relevant for assessing functional abilities but does not specifically measure insight into their mental health condition.

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Correct Answer is D

Explanation

A. Denial:
Denial is a defense mechanism in which a person refuses to accept reality or acknowledge the existence of something that is evident to others. For example, a person diagnosed with a serious illness might deny that they are ill or refuse to believe the diagnosis. In this scenario, the client is not denying a reality; he is expressing anger and directing it toward the nurse.

B. Compensation:
Compensation is a defense mechanism where an individual overachieves in one area to compensate for real or imagined deficiencies in another area. For instance, someone who feels intellectually inferior might excel in sports to compensate for their perceived inadequacy. This is not applicable to the client's situation in the scenario provided.

C. Rationalization:
Rationalization involves providing logical or reasonable explanations to justify behaviors or feelings that might otherwise be unacceptable. For instance, a person might rationalize a failure by blaming external factors rather than accepting personal responsibility. In the scenario, the client is not offering rationalizations but is expressing direct anger.

D. Displacement:
Displacement occurs when emotions, especially anger or frustration, are redirected from the original source to a less threatening target. For example, a person who is angry with their boss might come home and take out their frustration on their family members. In the given situation, the client is displacing his anger from his partner onto the nurse, asking her to leave, making displacement the most appropriate choice.

A. Instruct the client to consume a low-sodium diet to decrease hand tremors. B. Teach the client to take the lithium in a single daily dose C. Contact the provider for a possible decrease in the lithium dosage. D. Encourage the client to take naproxen sodium to decrease tremors.

Correct Answer is C

Explanation

A. Instruct the client to consume a low-sodium diet to decrease hand tremors:
While maintaining a stable sodium intake is important for individuals taking lithium to avoid fluctuations in lithium levels, a low-sodium diet is not specifically indicated to address hand tremors caused by lithium. Adjusting sodium levels is more about maintaining a consistent intake to stabilize lithium levels over time.

B. Teach the client to take the lithium in a single daily dose:
Lithium is often prescribed in divided doses to maintain stable blood levels throughout the day and minimize side effects. However, the dosing regimen (once or multiple times a day) is usually determined by the healthcare provider based on the individual's needs. Changing the dosing frequency is not the primary intervention for managing hand tremors.

C. Contact the provider for a possible decrease in the lithium dosage:
Hand tremors are a common side effect of lithium. If a client is experiencing bothersome side effects within the therapeutic range, the appropriate action is to contact the healthcare provider. The provider can assess the situation, possibly adjust the dosage, or explore other management options to alleviate the tremors while maintaining the therapeutic effect of the medication.

D. Encourage the client to take naproxen sodium to decrease tremors:
Encouraging the client to take naproxen sodium or any other nonsteroidal anti-inflammatory drug (NSAID) is not recommended when the client is on lithium therapy. NSAIDs can interact with lithium, potentially leading to increased lithium levels and toxicity. Combining these medications should be avoided.

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A nurse is conducting a mental status examination. Which of the following questions should the nurse ask to determine the client's insight?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?

Correct Answer is D

Explanation

A nurse in a community mental health clinic is assessing a client who began taking lithium carbonate 5 days ago. The client reports fine hand tremors and has a current lithium level of 1.2 mEq/L. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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